Virtually every part of the eye and
ocular adnexa can be affected. Early
ocular manifestations consist primarily
of follicular conjunctivitis; less
commonly, periorbital edema and
subconjunctival hemorrhage may
occur. Later, inflammations ranging
from iridocylitis to panuveitis are possible.
Bilateral keratitis is recognized
as a late manifestation of LD.

Ocular inflammation may be the
first and only sign of a systemic disease
process such as Lyme disease.
When encountered, appropriate laboratory
studies are required to determine
the underlying cause. Idiopathic
uveitis is a diagnosis of exclusion.

Case report: We report a case of Lyme disease with diplopia as the first manifestation, without systemic symptoms in contrast with other cases of this disease. The serodiagnosis was confirmed by ELISA analysis and evaluation of cerebrospinal fluid (CSF) antibodies. Symptoms readily vanished after the introduction of antibiotherapy.

Results
Sonography and contrast-enhanced computed tomography showed a large scleral mass (16 × 12 × 13 mm) in a patient with painful proptosis in the left eye with episcleral vascular dilation, reduction in bulbar motility, and chorioretinal folds in the upper temporal quadrant. Treatment with high-dose corticosteroids resulted in rapid regression of clinical symptoms and of the scleral mass. Intensive workup revealed immunoglobulin M antibodies (enzyme-linked immunoassay, Western immunoblot) and a positive lymphocyte transformation assay against B. burgdorferi. No other cause for posterior scleritis could be identified.

Conclusions
Posterior scleritis should be added to the list of ocular manifestations associated with Lyme disease. Because corticosteroids alone resulted in rapid improvement of clinical symptoms, the scleritis might be mediated by autoimmunologic mechanisms

Abstract
Objective
To report on the clinical findings in a patient with isolated left inferior rectus myositis associated with serologically confirmed Borrelia burgdorferi infection.

Design
Interventional case report.

Testing
Comprehensive clinical, laboratory, and imaging evaluation.

Results
Contrast-enhanced computed tomography showed a swollen inferior rectus muscle with infraorbital soft tissue swelling in a patient with diplopia and prior symptoms consistent with manifestations of Lyme disease. Positive serum and cerebrospinal fluid antibodies to B. burgdorferi by enzyme-linked immunoassay were confirmed by Western blot, and the cerebrospinal fluid/serum antibody ratio was elevated. No alternative cause for orbital myositis was found, and treatment with antibiotics resulted in a complete recovery.

Conclusions
Orbital myositis should be added to the expanding list of ophthalmic manifestations of Lyme disease. Correct diagnosis and appropriate antibiotic therapy may reduce the likelihood of further neurologic or ophthalmologic sequelae.

OBJECTIVE: To delineate the clinical manifestations of ocular Lyme borreliosis, while concentrating on new symptoms and findings and the phase of appearance of ophthalmologic disorders. DESIGN: Observational case series. PARTICIPANTS: Ten patients with Lyme borreliosis-associated ophthalmologic findings previously reported from the Helsinki University Central Hospital in addition to 10 new cases that have since been diagnosed. INTERVENTION/TESTING: The patients underwent medical and ophthalmologic evaluation. The diagnosis of Lyme borreliosis was based on medical history, clinical ocular and systemic findings, determinations of antibodies to Borrelia burgdorferi by enzyme-linked immunosorbent assay and immunoblot analysis, the detection of DNA of B. burgdorferi by polymerase chain reaction, and exclusion of other infectious and inflammatory causes. MAIN OUTCOME MEASURES: Ocular complaints, presenting ophthalmologic findings, and the stage of Lyme borreliosis were recorded. RESULTS: Four patients presented with a neuro-ophthalmologic disorder, five had external ocular inflammation, 10 patients had uveitis, and one had branch retinal vein occlusion. One patient developed episcleritis and one patient developed abducens palsy within 2 months of the infection incident. In the remaining 14 patients in whom the time of infection was traced, the ocular manifestations appeared in the late stage of Lyme borreliosis. Two patients with a neuro-ophthalmologic disorder and one with external ocular inflammation experienced severe photophobia, whereas the main reported symptom of the patients with uveitis was decreased visual acuity. Four patients with external ocular disease and one with a neuro-ophthalmologic disorder experienced severe periodic ocular or facial pain. Retinal vasculitis developed in seven patients with uveitis. CONCLUSIONS: Lyme borreliosis can cause a variety of ocular manifestations, which develop mainly in the late stage of the disease. Photophobia and severe periodic ocular pain can be characteristic symptoms of Lyme borreliosis. In the differential diagnosis of retinal vasculitis, Lyme borreliosis should be taken into account, especially in endemic areas.

PMID: 10711899

Listen to all,
plucking a feather from every passing goose,
but follow no one absolutely

Ocular manifestations in patients with Lyme borreliosis in northwest Croatia that occurred during the period between 1992 and 2001 were retrospectively analysed. The diagnosis of Lyme borreliosis was based on medical history, clinical manifestations, epidemiological data about tick contact, determinations of antibodies to Borrelia burgdorferi by serological assays, immunoblot analysis, therapeutic results and exclusion of other infectious agents of ocular disease. Of the eleven patients reported here with clinical manifestations of ocular Lyme borreliosis, 6 had chorioretinitis, 1 papillitis, 2 iridocyclitis, 1 occlusion of the arteriae centralis retinae, 1 neuritis retrobulbaris and 1 neuroretinitis. Diagnostic confirmation of LB was in most patients done by serological tests and/or by immunoblot method in serum. In the last few years we have also done culture and molecular diagnostic methods polymerase chain reaction (PCR)) in serum and cerebrospinal fluid. The patients were treated with 2 g of ceftriaxon i.v. per day for 14-21 days and/or with doxucyclin orally in a daily dose of 2 x 100 mg for 2-4 weeks. The therapeutic effect was followed up by regression of clinical symptoms (better visual acuity of the infected eye) and in changing of the specific antibody titer in serological tests. The authors emphasise the more detailed diagnostic proceedings of ocular Lyme borreliosis in patients with suspected Lyme borreliosis, an algorithm which contains data about residence in endemic area for LB, positive contact with ticks and/or the history of erythema migrans or any other Lyme borreliosis-like symptoms. For diagnostic confirmation it is necessary to use enzymeimmunoassay and immunoblot methods in serum, cerebrospinal fluid and aqueous humor, and isolation by culture or PCR can be used in the same diagnostic samples. Ocular Lyme borreliosis is an underdiagnosed disorder, because it is often unrecognised by ophthalmologists and due to weak seropositivity and seronegativity in the late ocular Lyme borreliosis. This is especially important in a highly endemic area for Lyme borreliosis like northwest Croatia, a border area of the central European andemic area for Lyme borreliosis.

PMID: 15628679

Listen to all,
plucking a feather from every passing goose,
but follow no one absolutely

BACKGROUND: A study was carried out to evaluate indirect enzyme-linked immunosorbent assay (ELISA), immunoblot analysis, and polymerase chain reaction (PCR) in the diagnostic work-up of ocular Lyme borreliosis. METHODS: Twenty patients with ocular Lyme borreliosis were examined. IgG and IgM antibodies to Borrelia burgdorferi were measured by ELISA in serum, and in cerebrospinal fluid (CSF) when indicated, and immunoblot analysis of B. burgdorferi IgG antibodies in serum was performed. A nested PCR was used to detect a segment of a gene coding for B. burgdorferi endoflagellin. The samples used in PCR testing were serum and CSF and in isolated cases conjunctiva and vitreous. RESULTS: Seventeen patients had elevated Borrelia antibodies in serum or CSF by ELISA. Seven patients, including two with negative ELISA, had a positive immunoblot. Seven of the 13 patients in whom PCR was examined during clinically active disease had a positive PCR result. Immunoblot analysis gave a negative result from the sera of five PCR-positive patients. CONCLUSIONS: For efficient diagnosis of ocular Lyme borreliosis, immunoblot analysis and PCR should be used in addition to ELISA. A positive PCR seems to be associated with a negative immunoblot.

PMID: 10090586

Listen to all,
plucking a feather from every passing goose,
but follow no one absolutely

OBJECTIVE: To report on the clinical findings in a patient with isolated left inferior rectus myositis associated with serologically confirmed Borrelia burgdorferi infection. DESIGN: Interventional case report. TESTING: Comprehensive clinical, laboratory, and imaging evaluation. RESULTS: Contrast-enhanced computed tomography showed a swollen inferior rectus muscle with infraorbital soft tissue swelling in a patient with diplopia and prior symptoms consistent with manifestations of Lyme disease. Positive serum and cerebrospinal fluid antibodies to B. burgdorferi by enzyme-linked immunoassay were confirmed by Western blot, and the cerebrospinal fluid/serum antibody ratio was elevated. No alternative cause for orbital myositis was found, and treatment with antibiotics resulted in a complete recovery. CONCLUSIONS: Orbital myositis should be added to the expanding list of ophthalmic manifestations of Lyme disease. Correct diagnosis and appropriate antibiotic therapy may reduce the likelihood of further neurologic or ophthalmologic sequelae.

PMID: 15121383

Listen to all,
plucking a feather from every passing goose,
but follow no one absolutely

Twelve patients with intraocular Lyme borreliosis suffering from vitreitis were treated with ceftriaxone intravenously. Eight patients had definitive Lyme borreliosis, and tentative diagnosis was made in four patients. After treatment with ceftriaxone, all 12 patients were followed up for more than one year. Vitreitis diminished in all patients and visual acuity improved in six patients. The best results were achieved in patients with definitive Lyme borreliosis.

Two patients in whom ocular Lyme disease was suspected and who had antibodies to Borrelia burgdorferi developed birdshot chorioretinopathy and carried the HLA-A29 antigen. In a series of 11 patients with birdshot chorioretinopathy who carried the HLA-A29 antigen, three patients had antibodies against B. burgdorferi as determined by either immunofluorescence assay, enzyme-linked immunosorbent assay, Western blot analysis, or a combination of these tests. Further studies will be necessary to evaluate whether this is a false-positive reaction or whether B. burgdorferi has a causative role in the pathogenesis of birdshot chorioretinopathy.

A case of chronic intermediate uveitis and associated classic snowbanking (pars planitis) with severe cystoid macular oedema probably due to Lyme borreliosis is reported. Despite a disease duration of 10 years the patient's ocular symptoms and visual acuity responded promptly to intravenous ceftriaxone treatment. This case demonstrates that periodic reevaluation of patients with intermediate uveitis is necessary to obtain a specific diagnosis which may include Lyme borreliosis.

PMID: 1540569

Listen to all,
plucking a feather from every passing goose,
but follow no one absolutely